Presbyterian Health Plan, Inc. Medical Policy Manual

The Medical Policy Manual is updated on a routine basis. Please click on the link below for a current summary of updates.
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All services provided must be medically necessary as determined by the member's practitioner or provider in consultation with PHP.

• Behavioral Health Clinical Medical Necessity Criteria (Medicaid Centennial Care)
• Behavioral Health Medical Necessity Criteria (Medicare/Commercial)
• Magellan NIA Medical Necessity Criteria

A

• Allergen Immunotherapy, MPM 44.0
• Allergy Testing, MPM 45.0
• Ambulance Services, MPM 1.1
• Autism Spectrum Disorders: Diagnosis and Treatment, MPM 1.4
• Autologous Chondrocyte Implantation (Carticel), MPM 3.2

B

• Balloon Dilation for ENT Procedures, MPM 2.12
• Bariatric Surgery (Weight Loss Surgery) for Medicare, MPM 2.82
• Bariatric Surgery (Weight Loss Surgery) for Non-Medicare, MPM 2.81
• Bariatric Surgery for Pediatric Population, MPM 40.0
• Blepharoplasty/Ptosis Surgery, MPM 2.7
• Bone Anchored Hearing Aid (BAHA), MPM 2.9
• Breast Surgical Procedures, MPM 27.0
• Breast Ultrasound, MPM 24.1
• Bronchial Thermoplasty For Treatment of Asthma, See MPM 36.0

C

• Cancer Clinical Trials, Routine Patient Care Costs, Coverage for Commercial and Medicaid, MPM 3.7
• Capsule Endoscopy, MPM 24.0
• Cervical and Lumbar Spinal Procedures, MPM 25.1
• Chimeric Antigen Receptor (CAR) T-cell Therapy, MPM 32.0
• Cholecystectomy, MPM 3.9
• Clinical Trial Coverage for Members Enrolled in a Medicare Plan, MPM 3.8
• Continuous Glucose Monitoring Systems (See DME: Diabetic Equipment, MPM 4.4)
• Corneal Cross-Linking for Keratoconus and Ectasia, MPM 28.0
• COVID-19 Testing, MPM 43.0
• Cranial Orthotic Devices, (See DME: Orthotics and Prosthetics, MPM 4.6)

D

• Diapers for Centennial Care Members, MPM 4.8
• Durable Medical Equipment: Alternating Electromagnetic Field Therapy for Glioblastoma, MPM 34.0
• Durable Medical Equipment: Bath Aids for Medicaid, MPM 48.0
• Durable Medical Equipment: For Individuals with Diabetes (Formerly Durable Medical Equipment: Diabetic Equipment), MPM 4.4
• Durable Medical Equipment: Miscellaneous, MPM 4.5
• Durable Medical Equipment: Orthotics and Prosthetics, MPM 4.6
• Durable Medical Equipment: Positive Airway Pressure (PAP) and Oral Appliances for Treatment of Obstructive Sleep Apnea, MPM 49.1
• Durable Medical Equipment: Pneumatic Compression Devices, MPM 5.0
• Durable Medical Equipment: Rehabilitation and Mobility Devices, MPM 4.2
• Durable Medical Equipment: Respiratory Devices, MPM 4.3

E

• Epidural Corticosteroid Injections, MPM 5.9
• Exhaled Nitric Oxide Testing for the Diagnosis/Management of Asthma, See MPM 36.0
• Extracorporeal Photopheresis, MPM 5.7
• Extracorporeal Shock Wave Therapy for Musculoskeletal Disorders, MPM 5.6

F

• Facet Joint Interventions for Pain Management (Formerly Paravertebral Facet Joint Denervation), MPM 16.6
• Foot Splints for Club Foot (See DME: Orthotics and Prosthetics, MPM 4.6)

G

• Gastric Electric Stimulation for the Treatment of Chronic Gastroparesis, MPM 7.2
• Gender Affirming Treatment and Surgery (Adult, 18 years of age and older), MPM 7.3
• Gender Affirming Treatment for Children and Adolescent (17 y/o and under), MPM 7.31
• Genetic and Genomic Testing (Disease Specific), MPM 7.1
• Genetic Testing: Cologuard for Colorectal Cancer Screening, MPM 7.4
• Genetic Testing for Breast Cancer Recurrence and Predictive, MPM 33.0
• Genetic Testing for Cutaneous Melanoma for Medicare, MPM 7.7
• Genetic Testing: Hypercoagulability/Thrombophilia, MPM 7.11
• Genetic Testing, InvisionFirst Liquid Biopsy for Lung Cancer, MPM 39.1 (Formerly MPM 37.0)
• Genetic Testing for Lynch Syndrome, MPM 7.5
• Genetic Testing: Next Generation Sequencing, MPM 29.0
• Genetic Testing for Non-Invasive Prenatal Testing (NIPT) (Formerly Non-Invasive Prenatal Testing (NIPT)), MPM 20.15
• Genetic Testing for Pancreatic Cyst (PathfinderTG®/PancraGen™), MPM 7.6
• Genetic Testing, Plasma-Based Genomic Profiling in Solid Tumors, MPM 39.0
• Genetic Testing for Prostate Cancer, MPM 7.8
• Genetic Testing for Uveal Melanoma, MPM 7.9
• Genetic Testing for Whole Exome Sequencing, MPM 7.12

H

• Home Health Care, for Medicare and Commercial, MPM 47.0
• Hyperbaric or Topical Oxygen Therapy (HBOT), MPM 8.6
• Hypoglossal Nerve Stimulator, MPM 46.0
• Hysterectomy, MPM 8.9

I

• Implantable Cardioverter Defibrillators (ICD), MPM 9.5
• Interspinous Process Decompression (IPD) System (Formerly X-STOP® Interspinous Process Decompression (IPD) System), See MPM 36.0
• Intervertebral Differential Dynamics Therapy (IDD Therapy), See MPM 36.0
• Investigative & New Technology Assessment List (Non-Covered Services), MPM 36.0

L

• LINX Reflux Management System for the Treatment of GERD, See MPM 36.0

M

• Medicaid Home Health Services, MPM 13.6
• Meniscal Allograft Transplantation, MPM 13.3
• Minimally Invasive Lumbar Decompression MILD and Percutaneous Image Guided Lumbar Decompression (PILD), MPM 13.5
• Mobile Cardiac Outpatient Telemetry™ (MCOT™) and Real-time Continuous Attended Cardiac Monitoring Systems, MPM 13.2
• Multi-biomarker (Vectra™ DA) test for Rheumatoid Arthritis, MPM 42.0

N

• Next Generation Sequencing, MPM 29.0
• Non-Invasive Prenatal Testing (NIPT), MPM 20.15

O

• Obstetric US 3D, 4D, 5D, MPM 15.4
• Osteogenic Bone Growth Stimulators, MPM 15.2
• Outpatient (in Facility) Observation, MPM 50.0

P

• Panniculectomy and Abdominoplasty, MPM 16.5
• Paravertebral Facet Joint Denervation (See Facet Joint Interventions for Pain Management, MPM 16.6)
• Percutaneous Coronary Interventions MPM 9.7
• Percutaneous Neuromodulation Therapy, See MPM 36.0
• Pharmacogenetic Testing for Warfarin Dosing (See Genetic and Genomic Testing, MPM 7.1)
• Pharmacogenomics Testing: Behavioral Health, for Medicare (Formerly Genesight Assay for Refractory Major Depression for Medicare), MPM 30.0
• Photodynamic Therapy for Ocular Conditions, MPM 16.15
• Plasma Exchange: Therapeutic Apheresis, MPM 16.11
• Platelet-Rich Plasma and Platelet-Derived Growth Factor Products, for the Treatment of Wounds and Other Injuries, MPM 16.16
• Positron Emission Tomography (PET), MPM 16.1
• Prophylactic, Risk Reduction Surgery, MPM 16.10
• Prostate: Surgical Treatment for Benign Prostate Hyperplasia, MPM 12.3
• Proton Beam Therapy (See Radiation Oncology: Proton Beam Therapy, MPM 16.14)

R

• Radiation Oncology: Proton Beam Therapy, MPM 16.14
• Restorative/Reconstructive/Cosmetic Surgery and Treatment, MPM 18.5

S

• Sacral Nerve Stimulation for Urinary and Fecal Incontinence, MPM 51.0
• Secca® Procedure for Fecal Incontinence, See MPM 36.0
• Sleep Studies, Attended (In-Laboratory) Full-Channel Polysomnography, MPM 49.0
• Subtalar Arthroereisis Implants for Pediatric Patients, See MPM 36.0

T

• Thermal Intradiscal Procedures (TIP), (includes IDET and Nucleoplasty) AKI: Intradiscal Electrothermal Therapy (IDET), See MPM 36.0
• Tissue-Engineered/Bioengineered Skin Substitutes (Application and Use), MPM 35.0
• Tonsillectomy, MPM 20.0
• Total Ankle Replacement, MPM 20.10
• Total Hip Resurfacing, MPM 20.9
• Total Joint Replacement Hip and Knee for Non-Medicare, MPM 20.14
• Total Joint Replacement Hip and Knee for Medicare, MPM 20.13
• Transcranial Magnetic Stimulation for Treatment Resistant Depression for Commercial, MPM 20.16
• Transcranial Magnetic Stimulation for Treatment Resistant Depression for Medicare, MPM 20.11
• Transoral Incisionless Fundoplication (TIF) for Treatment of GERD, MPM 20.12
• Transplants, Bone Marrow and Peripheral Stem Cell, MPM 20.3
• Transplants, Organ, MPM 20.6

U

• Unicompartmental Knee Replacement, MPM 41.0

V

• Vagus Nerve Stimulation for Epilepsy and Depression, MPM 22.4
• Varicose Vein and Venous Stasis Disease of Lower Extremity Procedures, MPM 22.1
• Virtual Colonoscopy, Diagnostic, MPM 22.0

W

• Water Vapor Thermal Therapy for LUTS/BPH, MPM 52.0
• Whole Breast Ultrasound, Semi-Automatic, See MPM 36.0